P321. Surgical Repair for an Iatrogenic Retrograde Type A Dissection Following New Generation Thoracic Branched Endoprosthesis

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Objective:
While thoracic endovascular aortic repair (TEVAR) offers a safe solution for type B aortic dissections, complications create complex surgical candidates. Here we describe a case of a TEVAR for acute-on-chronic type B3,10 aortic dissection that was complicated by type 1a endoleak three years after placement. This was treated with a thoracic branch endoprosthesis (TBE). One year later, the patient presented with retrograde type A dissection with pseudoaneurysm at the proximal seal zone, and underwent zone 2 aortic arch replacement. We believe this is the first reported case of an iatrogenic retrograde type A dissection following TBE.

Methods:
We conducted a retrospective chart review of this patient's clinical course.

Results:
A 62-year-old man with a history of hypertension, hyperlipidemia, and Graves' Disease, with a bovine arch presented with acute-on-chronic type B3,11 dissection. He was treated with two Conformable Thoracic Stent Grafts from zones 3 to 5. Three years later, CT angiogram demonstrated loss of seal and a penetrating ulcer at the proximal landing zone with interval growth of a dissection-associated aneurysm to 5.5cm. The proximal seal zone was extended using a TBE. One year later, he presented with chest pain and was found to have a retrograde type A aortic dissection, pericardial effusion, mediastinal fluid, an enlarging pseudoaneurysm at the proximal seal zone up to 1.1cm and a stably enlarged aortic root of 4.6cm. The patient was brought to the OR for zone 2 replacement of the aortic arch. Right axillary cannulation with an 8mm graft and right atrial venous cannulation was performed. Upon entering the pericardial space, 200cc of hemopericardium was evacuated. Both anterograde and retrograde cardioplegia were administered and the patient was cooled to 24°C. Upon opening the aorta, an intimal tear was noted just proximal to the TBE, extending proximally to the sinotubular junction. The left common carotid was cannulated for selective antegrade cerebral perfusion. Dissection into the proximal TEVAR was performed under circulatory arrest. The 32mm branched graft was inverted and inserted into the TEVAR graft to help facilitate the distal anastomosis. The proximal TEVAR stent was cut, and the anastomosis was reinforced with a felt strip. The branch graft was cannulated, the proximal graft cross-clamped, and full flow bypass was resumed. A 14mm and 8mm Y-graft was anastomosed to the innominate and left common carotid, respectively, and bilateral cerebral perfusion was resumed followed by completion of the proximal aortic anastomosis. Finally, the pre-made Y graft was anastomosed to the aortic graft, bypass was weaned, and the branched graft was closed. The patient recovered well without complications.

Conclusions:
We believe this to be the first case of a successful repair of iatrogenic retrograde type A dissection following TBE placement for type B dissection. This case represents successful surgical management of a rare complication with a favorable outcome. This complication demonstrates the importance of patient selection for TBE following type 1a endoleak after conventional TEVAR.

Authors
Andrew Jones (1), Shaelyn Cavanaugh (2), Hossein Amirjamshidi (2), Sarah Hoffman (1), Joshua Geiger (2), Daniel Lehane (1), Baqir Kedwai (1), Kazuhiro Hisamoto (2)
Institutions
(1) University of Rochester School of Medicine and Dentistry, Rochester, NY, (2) University of Rochester Medical Center, Rochester, NY

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